21 UÊUÊU ASSESSING HEART AND NECK VESSELS 417

Heart Covering and Walls

The pericardium is a tough, inextensible, loose-fitting, fibro-
serous sac that attaches to the great vessels and surrounds
Base of heart the heart. A serous membrane lining, the parietal pericardium,
secretes a small amount of pericardial fluid that allows for
smooth, friction-free movement of the heart. This same type

CHAPTER 21 Precordium of serous membrane covers the outer surface of the heart and
is known as the epicardium. The myocardium is the thickest layer
of the heart, made up of contractile cardiac muscle cells. The
endocardium is a thin layer of endothelial tissue that forms the

Assessing Heart and Apex and

innermost layer of the heart and is continuous with the endo-
thelial lining of blood vessels (Fig. 21-2).

Neck Vessels apical impulse

ELECTRICAL CONDUCTION
OF THE HEART
FIGURE 21-1 The heart and major blood vessels lie centrally in Cardiac muscle cells have a unique inherent ability. They can spon-
the chest behind the protective sternum. taneously generate an electrical impulse and conduct it through

Case Study and inferior vena cava return blood to the right atrium from the
upper and lower torso, respectively. The pulmonary artery exits
Malcolm Winchester, a 45-year-old the right ventricle, bifurcates, and carries blood to the lungs.
African American man, is being admit- The pulmonary veins (two from each lung) return oxygenated
blood to the left atrium. The aorta transports oxygenated Brachiocephalic artery
ted to the coronary care unit (CCU)
with a diagnosis of chest pain and pres- blood from the left ventricle to the body (Fig. 21-2). Left common carotid artery
sure. He is currently in no acute distress Pulmonary valve Left subclavian artery
and wonders why he is being admitted Heart Chambers and Valves
to the CCU. The heart consists of four chambers, or cavities: two upper Superior vena cava
chambers, the right and left atria, and two lower chambers, Aortic arch
the right and left ventricles. The right and left sides of the heart Pulmonary trunk
are separated by a partition called the septum. The thin-walled
Structure and Function atria receive blood returning to the heart and pump blood into
the ventricles. The thicker-walled ventricles pump blood out Left pulmonary
Right pulmonary
of the heart. The left ventricle is thicker than the right ventricle artery artery (branches)
The cardiovascular system is highly complex, consisting of the
because the left side of the heart has a greater workload. (branches)
heart and a closed system of blood vessels. To collect accu-
rate data and correctly interpret it, the examiner must have an The entrance and exit of each ventricle are protected
Ascending
understanding of the structure and function of the heart, the by one-way valves that direct the flow of blood through Left
aorta
great vessels, the electrical conduction system of the heart, the the heart. The atrioventricular (AV) valves are located at the pulmonary
cardiac cycle, the production of heart sounds, cardiac output, entrance into the ventricles. There are two AV valves: the tri- Right veins
and the neck vessels. This information helps the examiner to cuspid valve and the bicuspid (mitral) valve. The tricuspid valve pulmonary Left atrium
is composed of three cusps, or flaps, and is located between veins
differentiate between normal and abnormal findings as they
relate to the cardiovascular system. the right atrium and the right ventricle; the bicuspid (mitral) Aortic valve
valve is composed of two cusps and is located between the
left atrium and the left ventricle. Collagen fibers, called chor- Left AV
HEART AND GREAT VESSELS (mitral)
dae tendineae, anchor the AV valve flaps to papillary muscles Right valve
The heart is a hollow, muscular, four-chambered (left and right within the ventricles. atrium
atria, and left and right ventricles) organ located in the middle Open AV valves allow blood to flow from the atria into the
of the thoracic cavity between the lungs in the space called the ventricles. However, as the ventricles begin to contract, the AV
mediastinum. It is about the size of a clenched fist and weighs valves snap shut, preventing the regurgitation of blood into Right AV
approximately 255 g (9 oz) in women and 310 g (10.9 oz) in the atria. The valves are prevented from blowing open in the (tricuspid) Left
men. The heart extends vertically from the left second to the left reverse direction (i.e., toward the atria) by their secure anchors valve ventricle
fifth intercostal space (ICS) and horizontally from the right edge to the papillary muscles of the ventricular wall. The semilunar
of the sternum to the left midclavicular line (MCL). The heart can valves are located at the exit of each ventricle at the beginning Right ventricle
be described as an inverted cone. The upper portion, near the left of the great vessels. Each valve has three cusps that look like
second ICS, is the base; the lower portion, near the left fifth ICS half-moons, hence the name “semilunar.” There are two semi-
and the left MCL, is the apex. The anterior chest area that overlies lunar valves: the pulmonic valve is located at the entrance of the Inferior
the heart and great vessels is called the precordium (Fig. 21-1). The pulmonary artery as it exits the right ventricle and the aortic vena cava
Endocardium
right side of the heart pumps blood to the lungs for gas exchange valve is located at the beginning of the ascending aorta as it Apex
(pulmonary circulation); the left side of the heart pumps blood exits the left ventricle. These valves are open during ventricular Blood high in oxygen Myocardium
Interventricular
to all other parts of the body (systemic circulation). contraction and close from the pressure of blood when the Epicardium septum
The large veins and arteries leading directly to and away Blood low in oxygen
ventricles relax. Blood is thus prevented from flowing back-
from the heart are referred to as the great vessels. The superior ward into the relaxed ventricles (Fig. 21-2). FIGURE 21-2 Heart chambers, valves, and direction of circulatory flow.

416
418 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS
Ascending aorta
Superior
vena cava
Sinoatrial
node
Internodal
pathways
Right atrium
Atrioventricular
node
Atrioventricular
bundle (bundle
of His)
Right and left
bundle branches
Right ventricle Purkinje fibers
the heart. The generation and conduction of electrical impulses
by specialized sections of the myocardium regulate the events
associated with the filling and emptying of the cardiac cham-
bers. The process is called the cardiac cycle (see description in
next section).
Pathways
The sinoatrial (SA) node (or sinus node) is located on the pos-
terior wall of the right atrium near the junction of the supe-
rior and inferior vena cava. The SA node, with inherent rhyth-
micity, generates impulses (at a rate of 60–100 per minute)
that are conducted over both atria, causing them to contract
simultaneously and send blood into the ventricles. The cur-
rent, initiated by the SA node, is conducted across the atria to
the atrioventricular (AV) node located in the lower interatrial
septum (Fig. 21-3). The AV node slightly delays incoming elec-
trical impulses from the atria and then relays the impulse to
the AV bundle (bundle of His) in the upper interventricular
septum. The electrical impulse then travels down the right and
left bundle branches and the Purkinje fibers in the myocardium
of both ventricles, causing them to contract almost simultane-
ously. Although the SA node functions as the “pacemaker of
the heart,” this activity shifts to other areas of the conduction
system, such as the Bundle of His (with an inherent discharge of
40–60 per minute), if the SA node cannot function.
Electrical Activity
Electrical impulses, which are generated by the SA node and
travel throughout the cardiac conduction circuit, can be detected
on the surface of the skin. This electrical activity can be mea-
sured and recorded by electrocardiography (ECG, also abbreviated
Left atrium
Left ventricle
Chordae
tendineae
Papillary
muscle FIGURE 21-3 The electrical conduc-
tion system of the heart begins with
impulses generated by the sinoatrial
node (green) and circuited continu-
ously over the heart.
as EKG), which records the depolarization and repolarization of
the cardiac muscle. The phases of the ECG are known as P, Q, R,
S, and T. Box 21-1 describes the phases of the ECG.
THE CARDIAC CYCLE
The cardiac cycle refers to the filling and emptying of the heart’s
chambers. The cardiac cycle has two phases: diastole (relax-
ation of the ventricles, known as filling) and systole (contrac-
tion of the ventricles, known as emptying). Diastole endures
for approximately two-thirds of the cardiac cycle and systole is
the remaining one-third (Fig. 21-4).
Diastole
During ventricular diastole, the AV valves are open and the ven-
tricles are relaxed. This causes higher pressure in the atria than
in the ventricles. Therefore, blood rushes through the atria into
the ventricles. This early, rapid, passive filling is called early or
protodiastolic filling. This is followed by a period of slow passive
filling. Finally, near the end of ventricular diastole, the atria
contract and complete the emptying of blood out of the upper
chambers by propelling it into the ventricles. This final active
filling phase is called presystole, atrial systole, or sometimes the
“atrial kick.” This action raises left ventricular pressure.
Systole
The filling phases during diastole result in a large amount of
blood in the ventricles, causing the pressure in the ventricles to
be higher than in the atria. This causes the AV valves (mitral and
tricuspid) to shut. Closure of the AV valves produces the first heart
sound (S1), which is the beginning of systole. This valve closure
21 UÊUÊU ASSESSING HEART AND NECK VESSELS 419
BOX 21-1 PHASES OF THE ELECTROCARDIOGRAM
The phases of the electrocardiogram (ECG), which records UÊ P wave: Atrial depolarization; conduction of the impulse
depolarization and repolarization of the heart, are assigned throughout the atria.
letters: P, Q, R, S, and T. UÊ PR interval: Time from the beginning of the atrial depolar-
ization to the beginning of ventricular depolarization, that
is, from the beginning of the P wave to the beginning of
the QRS complex.
UÊ QRS complex: Ventricular depolarization (also atrial repo-
larization); conduction of the impulse throughout the ven-
tricles, which then triggers contraction of the ventricles;
measured from the beginning of the Q wave to the end of
the S wave.
UÊ ST segment: Period between ventricular depolarization and
the beginning of ventricular repolarization.
UÊ T wave: Ventricular repolarization; the ventricles return to
a resting state.
UÊ QT interval: Total time for ventricular depolarization and
repolarization, that is, from the beginning of the Q wave
to the end of the T wave; the QT interval varies with heart
rate.
UÊ U wave: May or may not be present; if present, it follows
the T wave and represents the final phase of ventricular
repolarization.
also prevents blood from flowing backward (a process known as pressure is now higher than the ventricular pressure, causing
regurgitation) into the atria during ventricular contraction. the AV valves to open and diast olic filling to begin again.
At this point in systole, all four valves are closed and the
ventricles contract (isometric contraction). There is now high
HEART SOUNDS
pressure inside the ventricles, causing the aortic valve to open
on the left side of the heart and the pulmonic valve to open Heart sounds are produced by valve closure, as just described. The
on the right side of the heart. Blood is ejected rapidly through opening of valves is silent. Normal heart sounds, characterized
these valves. With ventricular emptying, the ventricular pres- as “lub dubb” (S1 and S2), and occasionally extra heart sounds
sure falls and the semilunar valves close. This closure produces and murmurs can be auscultated with a stethoscope over the
the second heart sound (S2), which signals the end of systole. precordium, the area of the anterior chest overlying the heart
After closure of the semilunar valves, the ventricles relax. Atrial and great vessels.
contraction
relaxation
DIASTOLE SYSTOLE DIASTOLE
Isometric
Isometric
Rapid Slow Presystole Ejection Rapid
filling filling filling
(Protodiastolic)
Heart Sounds
S3 S4 S1 S2
R
FIGURE 21-4 The cardiac cycle consists
of filling and ejection. Heart sounds S2, Electrocardiogram
S3, and S4 are associated with diastole,
P T
while S1 is associated with systole. The
electrical activity of the heart is mea-
Q
sured throughout diastole and systole
by electrocardiography. S
420 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS 21 UÊUÊU ASSESSING HEART AND NECK VESSELS 421

Normal Heart Sounds
The first heart sound (S1) is the result of closure of the AV
valves: the mitral and tricuspid valves. As mentioned previ-
ously, S1 correlates with the beginning of systole (see Box 21-2
for more information about S1 and variations of S1). S1 (“lub”)
is usually heard as one sound but may be heard as two sounds
(see also Fig. 21-4). If heard as two sounds, the first compo-
nent represents mitral valve closure (M1); the second compo-
nent represents tricuspid closure (T1). M1 occurs first because
of increased pressure on the left side of the heart and because
of the route of myocardial depolarization. S1 may be heard
over the entire precordium but is heard best at the apex (left
MCL, fifth ICS).
BOX 21-2 UNDERSTANDING NORMAL S1 SOUNDS AND VARIATIONS
S1, which is the first heart sound, is produced by the atrio-
ventricular (AV) closing. S1 (the “lub” portion of “lub dubb”)
correlates with the beginning of systole.
The intensity of S1 depends on the position of the mitral
valve at the start of systole, the structure of the valve leaflets,
and how quickly pressure rises in the ventricles. All of these fac-
tors influence the speed and amount of closure the valve experi-
ences, which, in turn, determine the amount of sound produced.
Accentuated S1
An accentuated S1 sound is louder than an S2. This occurs when the mitral valve
is wide open and closes quickly. Examples include:
UÊ Hyperkinetic states in which blood velocity increases such as fever, anemia,
and hyperthyroidism
UÊ Mitral stenosis in which the leaflets are still mobile but increased ventricular
pressure is needed to close the valve
The second heart sound (S2) results from closure of the
semilunar valves (aortic and pulmonic) and correlates with
the beginning of diastole. S2 (“dubb”) is also usually heard
as one sound but may be heard as two sounds. If S2 is heard
as two sounds, the first component represents aortic valve
closure (A2) and the second component represents pulmonic
valve closure (P2). A2 occurs first because of increased pressure
on the left side of the heart and because of the route of myo-
cardial depolarization. If S2 is heard as two distinct sounds, it
is called a split S2. A splitting of S2 may be exaggerated during
inspiration and disappear during expiration. S2 is heard best at
the base of the heart. See Box 21-3 for more information about
variations of S2.
CLINICAL TIP
Normal variations in S1 are heard at the base and the
apex of the heart. S1 is softer at the base and louder at the
apex of the heart. An S1 may be split along the lower left
sternal border, where the tricuspid component of the sound,
usually too faint to be heard, can be auscultated. A split S1
heard over the apex may be an S4.
1ST CARDIAC BEGINNING OF NEXT
CYCLE CARDIAC CYCLE
S1 S2 S1
BOX 21-3 VARIATIONS IN S2
The S2 sound depends on the closure of the aortic and pul- P2 (pulmonic valve sound). If either sound is absent, no split
monic valves. Closure of the pulmonic valve is delayed by sounds are heard. The A2 sound is heard best over the second
inspiration, resulting in a split S2 sound. The components of right intercostal space. P2 is normally softer than A2.
the split sound are referred to as A2 (aortic valve sound) and
1ST CARDIAC BEGINNING OF NEXT
CYCLE CARDIAC CYCLE
Accentuated S2
An accentuated S2 means that S2 is louder than S1. This occurs in conditions
in which the aortic or pulmonic valve has a higher closing pressure. Exam-
ples include:
UÊ Increased pressure in the aorta from exercise, excitement, or systemic
hypertension (a booming S2 is heard with systemic hypertension)
S1
UÊ Increased pressure in the pulmonary vasculature, which may occur with
S1 S2
mitral stenosis or congestive heart failure
UÊ Calcification of the semilunar valve, in which the valve is still mobile, as in
pulmonic or aortic stenosis
Diminished S2
A diminished S2 means that S2 is softer than S1. This occurs in conditions
in which the aortic or pulmonic valves have decreased mobility. Examples
include:
UÊ Decreased systemic blood pressure, which weakens the valves, as in shock
UÊ Aortic or pulmonic stenosis, in which the valves are thickened and calci-
fied, with decreased mobility
S1 S2 S1
Normal (Physiologic) Split S2
A normal split S2 can be heard over the second or third left intercostal space. Expiration Inspiration
It is usually heard best during inspiration and disappears during expiration. S1 S2 S1 S2
Over the aortic area and apex, the pulmonic component of S2 is usually too
faint to be heard and S2 is a single sound resulting from aortic valve closure.
In some clients, S2 may not become single on expiration unless the client
sits up. Splitting that does not disappear during expiration is suggestive of
heart disease.

Diminished S1
A 2P 2 A2 P2
Sometimes the S1 sound is softer than the S2 sound. This occurs when the mitral
valve is not fully open at the time of ventricular contraction and valve closing.
Examples include: Wide Split S2
UÊ Delayed conduction from the atria to the ventricles as in first-degree heart This is an increase in the usual splitting that persists throughout the Expiration Inspiration
block, which allows the mitral valve to drift closed before ventricular contrac- entire respiratory cycle and widens on expiration. It occurs when there is S1 S2 S1 S2
S1
tion closes it delayed electrical activation of the right ventricle. An example:
S1 S2 UÊ Right bundle branch block, which delays pulmonic valve closing
UÊ Mitral insufficiency in which extreme calcification of the valve limits mobility
UÊ Delayed or diminished ventricular contraction arising from forceful atrial con-
traction into a noncompliant ventricle, as in severe pulmonary or systemic
T T
hypertension
m m
Split S1 A2 P2 A2 P2
As named, a split S1 occurs as a split sound. This occurs when the left and right
ventricles contract at different times (asynchronous ventricular contraction). Fixed Split S2
Examples include: This is a wide splitting that does not vary with respiration. It occurs when Expiration Inspiration
UÊ Conduction delaying the cardiac impulse to one of the ventricles, as in bundle there is delayed closure of one of the valves. An example: S1 S2 S1 S2
branch block UÊ Atrial septal defect and right ventricular failure, which delay pulmonic
UÊ Ventricular ectopy in which the impulse starts in one ventricle, contracting it valve closing
S1 S2 S1
first, and then spreading to the second ventricle

Varying S1
This occurs when the mitral valve is in different positions when contraction
occurs. Examples include:
A2 P2 A2 P2
UÊ Rhythms in which the atria and ventricles are beating independently of each
other
UÊ Totally irregular rhythm such as atrial fibrillation Continued on following page
S1 S2
S1 S2
422 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS 21 UÊUÊU ASSESSING HEART AND NECK VESSELS 423

BOX 21-3 VARIATIONS IN S2 (Continued) ASSESSMENT GUIDE 21-1 Auscultating Heart Sounds
Most nurses need many hours of practice in auscultating heart chambers instead of Erb’s point, mitral, and tricuspid areas when
1ST CARDIAC BEGINNING OF NEXT
CYCLE CARDIAC CYCLE sounds to assess a client’s health status and interpret findings ฀ ฀ ฀ ฀ ฀ ฀ ฀
proficiently and confidently. Practitioners may be able to recognize ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Reversed Split S2 an abnormal heart sound but may have difficulty determining what traditional areas. The alternative areas are the aortic area, pulmonic
This is a split S2 that appears on expiration and disappears on inspiration— Expiration Inspiration and where it is exactly. Continued exposure and experience increase area, left atrial area, right atrial area, left ventricular area, and right
also known as paradoxical split. It occurs when closure of the aortic valve is S1 S2 S1 S2 one’s ability to determine the exact nature and characteristics of ventricular area.
abnormally delayed, causing A2 to follow P2 in expiration. Normal inspira-
tory delay of P2 makes the split disappear during inspiration. An example: abnormal heart sounds. An added difficulty involves palpation, Cover the entire precordium. As you auscultate in all areas,
UÊ Left bundle branch block particularly of the apical impulse in clients who are obese or barrel concentrate on systematically moving the stethoscope from left to
chested. These conditions increase the distance from the apex of the ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
heart to the precordium. ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Where to Auscultate
A2 P2 ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Heart sounds can be auscultated in the traditional five areas on the
sternum but may be higher or lower
precordium, which is the anterior surface of the body overlying the
Accentuated A2 Accentuated P2 ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
heart and great vessels. The traditional areas include the aortic area,
An accentuated A2 is loud over the right, second intercos- An accentuated P2 is louder than or equal to an A2 sound. sternal border
the pulmonic area, Erb’s point, the tricuspid area, and the mitral or
tal space. This occurs with increased pressure, as in systemic This occurs with pulmonary hypertension, dilated pulmonary ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
hypertension and aortic root dilation because of the closer artery, and atrial septal defect. A wide split S2, heard even at apical area. The four valve areas do not reflect the anatomic location
nal border
position of the aortic valve to the chest wall. the apex, indicates an accentuated P2. of the valves. Rather, they reflect the way in which heart sounds
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
radiate to the chest wall. Sounds always travel in the direction of
Diminished A2 Diminished P2 ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
blood flow. For example, sounds that originate in the tricuspid valve
A diminished A2 is soft or absent over the right, second inter- A soft or absent P2 sound occurs with an increased anteropos- ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
are usually best heard along the left lower sternal border at the
costal space. This occurs with immobility of the aortic valve in terior diameter of the chest (barrel chest), which is associated over the sternum
calcific aortic stenosis. with aging, pulmonic stenosis, or COPD (chronic obstructive fourth or fifth intercostal space.
pulmonary disease). Traditional Areas of Auscultation
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
the base of the heart
Extra Heart Sounds ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
length before contraction (preload); the greater the preload, ฀ ฀ ฀ ฀
S3 and S4 are referred to as diastolic filling sounds, or extra heart ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ 1
sounds, which result from ventricular vibration secondary to the greater the stroke volume. This holds true unless the heart
muscle is stretched so much that it cannot contract effectively. ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ AO
2
rapid ventricular filling. If present, S3 can be heard early in dias- ฀ ฀ ฀ ฀ PA
tole, after S2 (Fig. 21-4, p. 419). S4 also results from ventricular ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ 3
blood during contraction (afterload); increased afterload ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
vibration but, contrary to S3, the vibration is secondary to ven- LA
sternal border 4
tricular resistance (noncompliance) during atrial contraction. If results in decreased stroke volume. RA
LV
present, S4 can be heard late in diastole, just before S1 (Fig. 21-4, ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ - RV 5
p. 419). S3 is often termed ventricular gallop, and S4 is called atrial traction of the myocardium); conditions that cause an asyn-
gallop. Extra heart sounds are described further in the Physical chronous contraction decrease stroke volume. Aortic area
Assessment section of the text and in Assessment Guide 21-1. ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
compliance decreases stroke volume.
Murmurs ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ -
dium under given loading conditions; increased contractil- Pulmonic area
Blood normally flows silently through the heart. There are
conditions, however, that can create turbulent blood flow ity increases stroke volume.
Although cardiac muscle has an innate pattern of contractil- How to Auscultate
in which a swooshing or blowing sound may be auscultated Erb's point
ity, cardiac activity is also mediated by the autonomic nervous Position yourself on the client’s right side. The client should be
over the precordium. Conditions that contribute to turbulent
system to respond to changing needs. The sympathetic impulses Tricuspid area supine, with the upper trunk elevated 30 degrees. Use the dia
blood flow include (1) increased blood velocity, (2) structural
increase heart rate and, therefore, cardiac output. The parasym- phragm of the stethoscope to auscultate all areas of the precordium
valve defects, (3) valve malfunction, and (4) abnormal cham-
pathetic impulses, which travel to the heart by the vagus nerve, ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
ber openings (e.g., septal defect). Mitral (apical)
decrease the heart rate and, therefore, decrease cardiac output. ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
area
firmly to the chest, but apply the bell lightly.
CARDIAC OUTPUT Focus on one sound at a time as you auscultate each area of the
NECK VESSELS precordium. Start by listening to the heart’s rate and rhythm. Then
Cardiac output (CO) is the amount of blood pumped by the
Assessment of the cardiovascular system includes evaluation Midsternum identify the first and second heart sounds, concentrate on each heart
ventricles during a given period of time (usually 1 minute)
of the vessels of the neck: the carotid artery and the jugular veins Midclavicular line sound individually, listen for extra heart sounds, listen for murmurs,
and is determined by the stroke volume (SV) multiplied by
(Fig. 21-5, p. 424). Assessment of the pulses of these vessels and finally listen with the client in different positions.
the heart rate (HR): SV × HR = CO. The normal adult cardiac
Alternative Areas of Auscultation
output is 5 to 6 L/min. reflects the integrity of the heart muscle. CLINICAL TIP
In reality, the areas described overlap extensively and sounds pro
duced by the valves can be heard all over the precordium. Therefore, Closing your eyes reduces visual stimuli and
Stroke Volume Carotid Artery Pulse distractions, and may enhance your ability to concentrate
it is important to listen to more than just five specific points on
Stroke volume is the amount of blood pumped from the The right and left common carotid arteries extend from the on auditory stimuli.
the precordium. Keep overlap in mind and use the names of the
heart with each contraction (stroke volume from the left ven- brachiocephalic trunk and the aortic arch, and are located
tricle is usually 70 mL). Stroke volume is influenced by several in the groove between the trachea and the right and left ster-
factors: nocleidomastoid muscles. Slightly below the mandible, each
424 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS 21 UÊUÊU ASSESSING HEART AND NECK VESSELS 425

a
QUESTION RATIONALE
External v
carotid artery L ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ Other symptoms that may occur include dyspnea, diaphoresis, pallor,
y nausea, palpitations, or tachycardia. Pain is usually seen in clients
Internal x D ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ with angina. However some clients may experience these other
carotid artery the pain? symptoms without the pain.

Carotid sinus S ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
possible pain.
Left common
carotid artery S1 S2 S1 S2 P ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Thyroid
artery and vein External jugular ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
FIGURE 21-6 Jugular venous pulse wave reflects pressure levels
vein
in the heart. ฀ ฀ ฀ ฀ ฀
A ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Decreased jugular venous pressure occurs with reduced left
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Internal jugular
ventricular output or reduced blood volume. The right inter-
vein nal jugular vein is most directly connected to the right atrium, Tachycardia and Palpitations
and provides the best assessment of pressure changes. Compo-
Left subclavian nents of the jugular venous pulse follow: Does your heart ever beat faster? Tachycardia may be seen with weak heart muscles, an attempt by the
artery ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ heart to increase cardiac output.
Left subclavian contraction ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ Palpitations may occur with an abnormality of the heart’s conduc
vein ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
FIGURE 21-5 Major neck vessels, including the carotid arteries atrial floor during ventricular systole cardiac output by increasing the heart rate. Palpitations may cause
and jugular veins. ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ the client to feel anxious.
increased atrial pressure
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ - Other Symptoms
bifurcates into an internal and external carotid artery. They tricle and decreased atrial pressure
supply the neck and head, including the brain, with oxygen- Figure 21-6 illustrates the jugular venous pulse. Do you tire easily? Do you experience fatigue? Describe when the Fatigue may result from compromised cardiac output. Fatigue
ated blood. The carotid artery pulse is a centrally located arterial ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ related to decreased cardiac output is worse in the evening or as the
pulse. Because it is close to the heart, the pressure wave pul- particular time of day? day progresses, whereas fatigue seen with depression is ongoing
sation coincides closely with ventricular systole. The carotid Health Assessment throughout the day.
arterial pulse is good for assessing amplitude and contour of
the pulse wave. The pulse should normally have a smooth, ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ Dyspnea may result from congestive heart failure, pulmonary disor
COLLECTING SUBJECTIVE DATA: ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ders, coronary artery disease, myocardial ischemia, and myocardial
rapid upstroke that occurs in early systole and a more gradual
THE NURSING HEALTH HISTORY breath? Do you have difficulty breathing when you are lying down? infarction. Dyspnea may occur at rest, during sleep, or with mild,
downstroke.
Subjective data collected about the heart and neck vessels helps How many pillows do you use to sleep? Does the difficulty breathing moderate, or extreme exertion. Orthopnea is the need to sit more up
Jugular Venous Pulse and Pressure the nurse to identify abnormal conditions that may affect the wake you up at night? ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
There are two sets of jugular veins: internal and external. The client’s ability to perform activities of daily living (ADLs) and ฀ ฀ ฀ ฀ ฀ ฀ paroxysmal nocturnal dyspnea ฀ ฀
internal jugular veins lie deep and medial to the sternocleido- to fulfill his or her role and responsibilities. Data collection seen with heart failure due to redistribution of fluid from the ankles
mastoid muscle. The external jugular veins are more super- also provides information on the client’s risk for cardiovascu- to the lungs when one lies down at night.
ficial; they lie lateral to the sternocleidomastoid muscle and lar disease and helps to identify areas for which health educa- ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ Fluid accumulation in the lungs from heart failure can cause one to
above the clavicle. The jugular veins return blood to the heart tion is needed. The client may not be aware of the significant appearance. ฀ ฀ ฀ ฀ ฀sputum.
from the head and neck by way of the superior vena cava. role that health promotion activities can play in preventing
Assessment of the jugular venous pulse is important for deter- cardiovascular disease. Do you experience dizziness? Dizziness may indicate decreased blood flow to the brain due to
mining the hemodynamics of the right side of the heart. The When compiling the nursing history of current complaints myocardial damage. However, there are several other causes for
level of the jugular venous pressure reflects right atrial (central or symptoms, personal and family history, and lifestyle and dizziness such as inner ear syndromes, decreased cerebral circulation,
venous) pressure and, usually, right ventricular diastolic filling health practices, remember to thoroughly explore signs and and hypotension.
pressure. Right-sided heart failure raises pressure and volume, symptoms that the client brings to your attention either inten- Dizziness may put the client at risk for falls.
thus raising jugular venous pressure. tionally or inadvertently.

฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ Increased renal perfusion during periods of rest or recumbent posi

History of Present Health Concern so, how many times each night? tions may cause nocturia, which occurs with heart failure.

QUESTION RATIONALE ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ Edema in both lower extremities at night is seen in heart failure due
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ to a reduction of blood flow out of the heart, causing blood returning
Chest Pain it in one or both legs? to the heart to back up in the organs and dependent areas of the
body.
Do you experience chest pain? If the client answers yes, use Chest pain can be cardiac, pulmonary, muscular, or gastrointestinal in
COLDSPA to explore the symptom. ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ Cardiac pain may be overlooked or misinterpreted as gastrointestinal
C ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ of squeezing around the heart; a steady, severe pain; and a sense of it? How often do you experience it? problems. Gastrointestinal pain may occur after meals and is relieved
฀ ฀ pressure. It may radiate to the left shoulder and down the left arm with antacids. Cardiac pain may occur anytime, is not relieved with
or to the jaw. Diaphoresis and pain worsened by activity are usually antacids, and worsens with activity.
O ฀ ฀ ฀ ฀
related to cardiac chest pain.
Continued on following page
426 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS 21 UÊUÊU ASSESSING HEART AND NECK VESSELS 427

Personal Health History QUESTION RATIONALE

QUESTION RATIONALE Describe your daily activities. How are they different from your Heart disease may impede the ability to perform daily activities.
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ Exertional dyspnea or fatigue may indicate heart failure. An inability
Have you been diagnosed with a heart defect or a murmur? Congenital or acquired defects affect the heart’s ability to pump, breath limit your ability to perform daily activities? Describe. Are you to complete activities of daily living may necessitate a referral for
decreasing the oxygen supply to the tissues. able to care for yourself? home care.
Have you ever had rheumatic fever? ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ Has your heart disease had any effect on your sexual activity? Many clients with heart disease are afraid that sexual activity will
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ precipitate chest pain. If the client can walk one block or climb two
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ flights of stairs without experiencing symptoms, it is generally ac
hemolytic streptococci and results in inflammation of all layers of the ceptable for the client to engage in sexual intercourse. Nitroglycerin
heart, impairing contraction and valvular function. can be taken before intercourse as a prophylactic for chest pain. In
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Have you ever had heart surgery or cardiac balloon interventions? Previous heart surgery may change the heart sounds heard during
the workload on the heart.
auscultation. Surgery and cardiac balloon interventions indicate prior
cardiac compromise. How many pillows do you use to sleep at night? Do you get up to If heart function is compromised, cardiac output to the kidneys is
urinate during the night? Do you feel rested in the morning? reduced during episodes of activity. At rest, cardiac output increases,
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ A prior ECG allows the health care team to evaluate for any changes
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
one performed? Do you know the results? in cardiac conduction or previous myocardial infarction.
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Have you ever had a blood test called a lipid profile? Based on your Dyslipidemia presents the greatest risk for the developing coronary failure. In addition, these two conditions may also impede the ability
last test, do you know what your cholesterol levels were? artery disease. Elevated cholesterol levels have been linked to the to get adequate rest.
฀ ฀ ฀ ฀ ฀ ฀
How important is having a healthy heart to your ability to feel good ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Do you take medications or use other treatments for heart disease? Clients may have medications prescribed for heart disease but may ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ not take them regularly. Clients may skip taking their diuretics be do you have? U.S. women surveyed, 9.7% identified heart disease as the disease they
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
because of the adverse effects on sexual energy. Education about
medications may be needed.

Do you monitor your own heart rate or blood pressure? ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀

the client is taking cardiotonic or antihypertensive medications. A
demonstration is necessary to ensure appropriate technique.
Case Study
Family History
The case study introduced at the beginning of the chapter is now used to demonstrate how the nurse contin-
QUESTION RATIONALE ues to explore Mr. Winchester, who is not in acute distress, but has the presenting symptoms of chest pain
and pressure. The COLDSPA pneumonic is used as follows.
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ A genetic predisposition to these risk factors increases a client’s
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ chance for developing heart disease.
฀ ฀ ฀ ฀
Mnemonic Question Data Provided
Lifestyle and Health Practices
Character Describe the sign or symptom (feel- “It feels like pressure in the middle of my chest.”
QUESTION RATIONALE ing, appearance, sound, smell, or taste
if applicable).
Do you smoke? How many packs of cigarettes per day and for how ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
many years? ฀ ฀ ฀ ฀ Onset When did it begin? “The pressure-like pain started after I ate supper and sat
down to watch TV. Usually I don’t have any chest pain
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ Stress has been identified as a possible risk factor for heart disease. unless I’m doing something physical, like yard work.”
with it?
Location Where is it? Does it radiate? Does it “It hurts in the middle of my chest and goes down my
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ An elevated cholesterol level increases the chance of fatty plaque occur anywhere else? left arm.”
formation in the coronary vessels.
Duration How long does it last? Does it recur? “Usually the pain only lasts a couple of minutes. But, this
How much alcohol do you consume each day/week? Excessive intake of alcohol has been linked to hypertension. More time it lasted a lot longer, maybe 20 minutes, and that was
than two drinks per day for men, or one drink per day for women, scary. I have been having chest pain off and on for a couple
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ of months and thought it was just indigestion.”
Severity How bad is it? or How much does it “Right now I don’t hurt, but when my wife brought me
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ A sedentary lifestyle is a known modifiable risk factor contributing to bother you? to the emergency department, I was very uncomfortable.”
heart disease. Aerobic exercise three times per week for 30 minutes Upon further questioning, Mr. Winchester rated his pain at
is more beneficial than anaerobic exercise or sporadic exercise in the onset of this episode as 8 on a scale of 0–10. Over the
preventing heart disease. past 2 months, he rated his pain as a 4–5 on a scale of 0–10.
Currently, he denies any pain.

Continued on following page

428 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS
Mnemonic Question
Pattern What makes it better or worse?
Associated factors/ What other symptoms occur with it?
How it Affects the How does it affect you?
client
After investigating Malcolm Winchester’s concerns
about chest pain, the nurse continues with the health
history.
Mr. Winchester denies heart defect, murmur, history of
rheumatic fever, cardiac surgery or intervention, previous
ECG, or medications for heart disease. He reports having an
annual lipid profile provided by his employer. He remem-
bers that some of the numbers were “high” but cannot
recall the actual numbers. He also admits that he has been
told that his blood pressure was a “little” high. However, he
cannot recall any specific readings.
According to Mr. Winchester, he has a strong family his-
tory of hypertension and type 2 diabetes: Both his parents
had both conditions. His mother died of a cerebral vascular
accident at age 62. His father died at age 58 of an acute
myocardial infarction. Maternal and paternal grandparents
are deceased due to “heart problems.”
21-1 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION:
CORONARY HEART DISEASE
INTRODUCTION
Heart disease is a broad category used to capture a range of
diseases, including diseases of blood vessels, such as coronary
artery disease; heart rhythm problems (arrhythmias); heart
infections; and congenital heart defects (Mayo Clinic, 2011).
Mayo Clinic staff write that cardiovascular disease is often
used interchangeably with heart disease and “refers to con-
ditions that involve narrowed or blocked blood vessels that
can lead to a heart attack, chest pain (angina) or stroke.” The
consequences of cardiovascular disease are “serious illness
and disability, decreased quality of life, and hundreds of bil-
lions of dollars in economic loss every year,” and heart disease
is the leading cause of death in the United States (Healthy
People 2020, 2012).
Although the complexity of how heart disease develops is
still being studied, it is well recognized that lifestyle affects
the disease and healthy changes in lifestyle may reduce or
reverse vascular changes leading to the disease.
HEALTHY PEOPLE 2020 GOAL
Overview
Healthy People 2020 (2012) addresses the topic of cardiovas-
cular disease as comprised of heart disease and stroke. In this
book, stroke is covered in the Chapter 25.
GOAL
UÊ Improve cardiovascular health and quality of life through
prevention, detection, and treatment of risk factors for
Data Provided
“Stopping whatever I was doing made the pain go away
until today.”
“Before today I only had the chest pressure with the pain.
Today was different. I felt light-headed, sweaty, and sick
to my stomach. It was hard to take a deep breath. I hadn’t
been worried until today, and I have to admit that I was
scared.” Mr. Winchester denies having palpitations, dys-
pnea, nocturia, peripheral edema, or indigestion.
Mr. Winchester reports that he started smoking at age
17 and quit at age 30. He smoked 2 packs per day for
13 years (26 pack years). He reports having a stressful job as
a supervisor in a local factory, and relieves stress by watch-
ing television. In the past 24 hours, Mr. Winchester has
฀ ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀
mashed potatoes, gravy, green beans, and water; evening
฀ ฀ ฀ ฀
Mr. Winchester has no formal exercise regimen. He reports
that he exercises when he does yard work every weekend.
Mr. Winchester reports that in the past 2–3 months he
has “slowed down.” He wonders if maybe his heart has
been “acting up.”
Mr. Winchester reports that there has been no change in
his sexual activity. He states that he sleeps with one pillow
and feels rested after sleep.
heart attack and stroke; early identification and treatment
of heart attacks and strokes; and prevention of repeat car-
diovascular events.
OBJECTIVES
UÊ (Developmental) Increase overall cardiovascular health in
the U.S. population (being developed)
UÊ Reduce coronary heart disease deaths from 126.0 per
100,000 population in 2007 to 100.8.
UÊ Increase the proportion of adults 18 years of age and older
who have had their blood pressure measured within the
preceding 2 years and can state whether their blood pres-
sure was normal or high from 90.6% in 2008 to 92.6%.
UÊ Increase the proportion of adults who have had their
blood cholesterol checked within the preceding 5 years
from 74.6% of adults aged 18 years and older to 81.2%.
UÊ Reduce the proportion of adults 20 years of age and older
with high total blood cholesterol levels of 240 mg/dL or
greater from 15.0% in 2005–2008 to 13.5%.
UÊ (Developmental) Increase the proportion of adults with
prehypertension who meet the recommended guidelines
(being developed).
UÊ (Developmental) Increase the proportion of adults with hy-
pertension who meet the recommended guidelines (being
developed).
UÊ Increase the proportion of adults aged 20 years and older
who are aware of, and respond to, early warning symp-
toms and signs of a heart attack.
UÊ Reduce hospitalizations of older adults with heart failure
as the principal diagnosis.
SCREENING
The U.S. Preventive Services Task Force (USPSTF, 2011) recom-
mends against routine screening with resting electrocardiog-
raphy (ECG), exercise treadmill test (ETT), or electron-beam
computerized tomography (EBCT) scanning for coronary cal-
cium for either the presence of severe coronary artery steno-
sis (CAS) or the prediction of coronary heart disease (CHD)
events in adults at low risk for CHD events, and found insuf-
ficient evidence to recommend for or against the use of these
screening techniques in adults at increased risk for CHD.
Screening for risk of heart disease includes blood tests
for cholesterol level, glucose level and presence of C-reactive
protein, blood pressure measurement, a health history assess-
ing cardiovascular-related risks, and screening for peripheral
artery disease.
฀
฀ RISK ASSESSMENT
According to Healthy People 2020 (2012), the leading modifi-
able (controllable) risk factors for heart disease and stroke
that cause changes in the heart and blood vessels include:
UÊ High blood pressure
UÊ High cholesterol
UÊ Cigarette smoking
UÊ Diabetes
UÊ Poor diet and physical inactivity
UÊ Overweight and obesity
Lifeline Screening (n.d.) adds the following risk factors:
UÊ High C-reactive protein, often related to diet and exercise
levels
UÊ High blood glucose, often related to diet and exercise
UÊ Peripheral artery disease
Health.com (2008) listed the American Heart Association
nonmodifiable and modifiable risks factors for heart disease
to be (first four nonmodifiable, last six modifiable):
COLLECTING OBJECTIVE DATA:
PHYSICAL EXAMINATION
A major purpose of this examination is to identify any sign
of heart disease and initiate early referral and treatment. It
is important to remember that cardiovascular disease is the
number one cause of death in the United States (American
Heart Association [AHA], 2012).
Assessment of the heart and neck vessels is an essential
part of the total cardiovascular examination. It is important
to remember that additional data gathered during assessment
of the blood pressure, skin, nails, head, thorax and lungs, and
peripheral pulses all play a part in the complete cardiovascular
assessment. These additional assessment areas are covered in
Chapters 8, 14, 15, 19, and 22, respectively.
This chapter encompasses inspection, palpation, and aus-
cultation of the neck and anterior chest area (precordium).
Inspection is a fairly easy skill to acquire. However, auscultation
requires a lot of practice to develop expert proficiency. Nov-
ice practitioners may be able to recognize an abnormal heart
sound but may have difficulty determining what and where it is
exactly. Continued exposure and experience increase the practi-
tioner’s ability to determine the exact nature and characteristics
of abnormal heart sounds. In addition, it may be difficult to
21 UÊUÊU ASSESSING HEART AND NECK VESSELS 429
UÊ Age (more than 83% of those who die of heart disease are
65 years or older)
UÊ Being male
UÊ Family history (especially parents or close relative)
UÊ Race/ethnicity (Mexican Americans, American Indians,
native Hawaiians, and some Asian Americans have higher
rates compared to Caucasians)
UÊ Cigarette smoking (increases rate for heart disease by 2 to
4 times)
UÊ High cholesterol
UÊ High blood pressure
UÊ Sedentary lifestyle
UÊ Excessive weight
UÊ Diabetes mellitus
CLIENT EDUCATION
Because lifestyle has such an important effect on heart disease,
it is essential to teach ways to modify the risk of developing
the disease and tips on halting the progression of the disease.
Teach Clients
UÊ Stop smoking or enroll in a smoking cessation program.
UÊ Eat a healthy, well-rounded diet high in vegetables, fruits,
and fiber; avoid saturated fats and excessive sugars.
UÊ Reduce elevated cholesterol (though diet or per medica-
tion if prescribed).
UÊ Lower blood pressure (through weight loss and increased
activity).
UÊ Increase physical activity; participate in at least moderate
physical activity daily.
UÊ Work to achieve or maintain a healthy weight for height.
UÊ Manage diabetes if diagnosed.
UÊ Limit alcohol intake to recommendations of 1 drink per
day for women or 2 drinks per day for men.
UÊ Practice stress reducing techniques such as exercise, relax-
ation, meditation, yoga, recreational and diversional ac-
tivities from everyday work, hobbies, etc.
palpate the apical impulse in clients who are obese or barrel
chested: these conditions increase the distance from the apex
of the heart to the precordium.
Heart and neck vessel assessment skills are useful to the
nurse in all types of health care settings, including acute, clini-
cal, and home health care.
CLINICAL TIP
When performing a total body system examination
(see Chapter 28), it is often convenient to assess the heart
and neck vessels immediately after assessment of the thorax
and lungs.
Preparing the Client
Prepare clients for the examination by explaining that they will
need to expose the anterior chest. Explain to the client that it is
necessary to assume several different positions for this examina-
tion. Explain that you will need to place the client in the supine
position with the head elevated to about 30 degrees during aus-
cultation and palpation of the neck vessels and inspection, pal-
pation, and auscultation of the precordium. Tell the client that
it will be necessary to assume a left lateral position for palpation
of the apical impulse if you are having trouble locating the pulse
with the client in the supine position. In addition, explain to
430 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS 21 UÊUÊU ASSESSING HEART AND NECK VESSELS 431

Provide the client with as much modesty as possible during

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
the examination, describe the steps of the examination, and
answer any questions the client may have. These actions will Evaluate jugular venous pressure (Fig. The jugular vein should not be distended, ฀ ฀ ฀ ฀ ฀ ฀ ฀
help to ease any client anxiety. 21-8). Evaluate jugular venous pressure by ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Equipment watching for distention of the jugular vein. greater. ฀ ฀ ฀ ฀ ฀ ฀ ฀
It is normal for the jugular veins to be vis ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ ible when the client is supine. To evaluate
฀ ฀ jugular vein distention, position the client Clients with obstructive pulmonary disease
฀ ฀ ฀ ฀ ฀ in a supine position with the head of the may have elevated venous pressure only
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ during expiration.
฀ ฀ ฀ At each increase of the elevation, have
An inspiratory increase in venous pressure,
the client’s head turned slightly away from
called Kussmaul’s sign, may occur in clients
the side being evaluated. Using tangential
with severe constrictive pericarditis.
lighting, observe for distention, protrusion,
or bulging.
FIGURE 21-7 Asking the client to pull her breast upward and to
her side facilitates auscultation of heart sounds. CLINICAL TIP
In acute care settings, invasive
cardiac monitors (pulmonary artery
the client the necessity to assume a left lateral and sitting-up catheters) are used for precisely measur-
and leaning-forward position so that you can auscultate for the ing pressures.
presence of any abnormal heart sounds. These positions may Auscultation and Palpation No blowing or swishing or other sounds are A bruit, a blowing or swishing sound caused
bring out an abnormal sound not detected with the client in the heard. by turbulent blood flow through a narrowed
supine position. Make sure you explain to the client that you Physical Assessment Auscultate the carotid arteries if the client vessel, is indicative of occlusive arterial
will be listening to the heart in a number of places and that this ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ Pulses are equally strong; a 2+ or normal disease. However, if the artery is more than
Remember these key points during examination:
does not necessarily mean that anything is wrong. cardiovascular disease. Place the bell of with no variation in strength from beat to ฀ ฀ ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
the stethoscope over the carotid artery and beat. Contour is normally smooth and rapid heard.
CLINICAL TIP major coronary vessels to identify and interpret heart
ask the client to hold his or her breath for on the upstroke and slower and less abrupt
In women with large breasts, it may be helpful to ask the sounds and electrocardiograms accurately.
a moment so that breath sounds do not on the downstroke. The strength of the Pulse inequality may indicate arterial con
client to pull her breast upward and to her side when you are ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ striction or occlusion in one carotid.
auscultating for heart sounds (Fig. 21-7). older adult client.
CLINICAL TIP ฀ ฀ ฀ ฀ ฀
Always auscultate the carotid Pulse Amplitude Scale shock, or decreased cardiac output.
arteries before palpating because palpa- 0 = Absent
tion may increase or slow the heart rate, + =฀ A bounding, firm pulse may indicate hyper
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS changing the strength of the carotid 2+ = Normal volemia or increased cardiac output.
impulse heard. 3+ = Increased
Neck Vessels Variations in strength from beat to beat
+ = Bounding
or with respiration are abnormal and may
INSPECTION ฀ ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀
Observe the jugular venous pulse. The jugular venous pulse is not normally Fully distended jugular veins with the cli
Inspect the jugular venous pulse by stand visible with the client sitting upright. This ฀ ฀ ฀ ฀ ฀ ฀ ฀ A delayed upstroke may indicate aortic
ing on the right side of the client. The client position fully distends the vein, and pulsa indicate increased central venous pressure stenosis.
should be in a supine position with the tions may or may not be discernible. that may be the result of right ventricular
฀ ฀ ฀ ฀ ฀ ฀ failure, pulmonary hypertension, pulmonary
the head and torso are on the same plane. emboli, or cardiac tamponade.
Ask the client to turn the head slightly to
the left. Shine a tangential light source
onto the neck to increase visualization
of pulsations as well as shadows. Next,
inspect the suprasternal notch or the area
around the clavicles for pulsations of the
internal jugular veins.
CLINICAL TIP
Be careful not to confuse pulsa-
tions of the carotid arteries with
pulsations of the internal jugular
veins.
FIGURE 21-8 Assessing jugular venous pressure. FIGURE 21-9 Auscultating the carotid artery.
Continued on following page
432 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS 21 UÊUÊU ASSESSING HEART AND NECK VESSELS 433

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Neck Vessels (Continued) PALPATION

Palpate the carotid arteries. Palpate each Arteries are elastic and no thrills are noted. ฀ ฀ ฀ ฀ ฀ Palpate the apical impulse. Remain on The apical impulse is palpated in the mitral The apical impulse may be impossible to pal
carotid artery alternately by placing the pads sis. Thrills may indicate a narrowing of the the client’s right side and ask the client to ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ pate in clients with pulmonary emphysema.
of the index and middle fingers medial to artery. remain supine. Use one or two finger pads ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
the sternocleidomastoid muscle on the neck to palpate the apical impulse in the mitral tap. The duration is brief, lasting through the displaced, more forceful, or of longer dura
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ tion, suspect cardiac enlargement.
the pulse, elasticity of the artery, and any ฀ ฀ ฀ obese clients or clients with large breasts,
฀ ฀ ฀ ฀ ฀ ฀ ฀ the apical impulse may not be palpable.
You may ask the client to roll to the left side
If you detect occlusion to better feel the impulse using the palmar OLDER ADULT
during auscultation, palpate ฀ ฀ ฀ ฀ ฀ ฀ CONSIDERATIONS
very lightly to avoid blocking circulation In older clients, the apical impulse
or triggering vagal stimulation and bra- CLINICAL TIP may be difficult to palpate because
dycardia, hypotension, or even cardiac If this apical pulsation cannot be of increased anteroposterior chest
arrest. palpated, have the client assume a left diameter.
lateral position. This displaces the heart
toward the left chest wall and relocates
the apical impulse farther to the left.

FIGURE 21-10 Palpating the carotid artery.

Palpate the carotid arteries individually A B

because bilateral palpation could result in
reduced cerebral blood flow. FIGURE 21-11 Locate the apical impulse with the finger pads (A); then palpate the apical impulse with the palmar surface (B).

OLDER ADULT Palpate for abnormal pulsations. Use No pulsations or vibrations are palpated in A thrill or a pulsation is usually associated
CONSIDERATION your palmar surfaces to palpate the apex, the areas of the apex, left sternal border, or with a grade IV or higher murmur.
Be cautious with older clients because left sternal border, and base. base.
atherosclerosis may have caused
obstruction and compression may easily AUSCULTATION
block circulation.
Auscultate heart rate and rhythm. Follow the ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Heart (Precordium) ฀ ฀ ฀ ฀ ฀ ฀ regular rhythm. A regularly irregular rhythm, ฀ ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ such as sinus arrhythmia when the heart rate result in decreased cardiac output. Refer cli
INSPECTION stethoscope at the apex and listen closely to increases with inspiration and decreases with ฀ ฀ ฀ ฀ ฀ ฀
Inspect pulsations.฀ ฀ ฀ ฀ ฀ The apical impulse may or may not be vis Pulsations, which may also be called heaves the rate and rhythm of the apical impulse. expiration, may be normal in young adults. atrial contraction or premature ventricular
supine position with the head of the bed ible. If apparent, it would be in the mitral or lifts, other than the apical pulsation are ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ ฀ atrial fibrillation and atrial flutter with
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ considered abnormal and should be evalu ฀ ฀ ฀ ฀ ฀
on the client’s right side and look for the api ฀ ฀ ฀ ฀ ฀ ฀ ฀ ated. A heave or lift may occur as the result ฀ ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ types of irregular patterns may predispose
cal impulse and any abnormal pulsations. result of the left ventricle moving outward of an enlarged ventricle from an overload of beats faster than male RPRs.
during systole. ฀ ฀ ฀ ฀ ฀ ฀ ฀ the client to decreased cardiac output, heart
CLINICAL TIP
describes abnormal ventricular impulses. CULTURAL CONSIDERATIONS ฀ ฀ ฀ ฀ ฀ ฀
The apical impulse was originally Non-Hispanic Black males have ฀
called the point of maximal impulse a lower mean RPR than those of
(PMI). However, this term is no longer non-Hispanic White males or Mexican
used because a maximal impulse may American males, while non-Hispanic
occur in other areas of the precordium Black females and Mexican American
as a result of abnormal conditions. females have slower mean RPRs than
non-Hispanic White females.

Continued on following page

434 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS 21 UÊUÊU ASSESSING HEART AND NECK VESSELS 435

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Heart (Precordium) (Continued) Auscultate for extra heart sounds. Use Normally no sounds are heard. A physiologic ฀ ฀ ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ S3 heart sound is a benign finding commonly ฀ ฀ ฀ ฀ ฀ ฀
If you detect an irregular rhythm, The radial and apical pulse rates should be ฀ ฀ ฀ ฀ ฀ ฀ to auscultate over the entire heart area. Note heard at the beginning of the diastolic pause A friction rub may also be heard during the
auscultate for a pulse rate deficit. This is identical. ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ in children, adolescents, and young adults. ฀ ฀ ฀ ฀ ฀ ฀
done by palpating the radial pulse while you indicate atrial fibrillation, atrial flutter, pre any extra sound heard. Auscultate during ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ 3 ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
auscultate the apical pulse. Count for a full mature ventricular contractions, and varying ฀ ฀ ฀ ฀ ฀ ฀ usually subsides upon standing or sitting up. ฀ ฀ ฀ ฀ ฀ ฀
minute. degrees of heart block. S and S2 A physiologic S heart sound may be heard of systole and diastole.
Auscultate to identify S1 and S2. Aus S corresponds with each carotid pulsation ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Auscultate during the diastolic pause ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ A pathologic S3฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ and is loudest at the apex of the heart. S2 ฀ ฀ ฀ ฀ ฀ 2 and the heard with ischemic heart disease, hyper
฀ ฀ ฀ ฀ ฀ 2฀ ฀ ฀ immediately follows after S and is loudest 50 with no evidence of heart disease, espe
next S cially after exercise. ฀ ฀ ฀ ฀ ฀ ฀
Remember these two sounds make up the at the base of the heart. myocardial disease.
cardiac cycle of systole and diastole. S starts CLINICAL TIP
systole, and S2 starts diastole. The space, or While auscultating, keep in A pathologic S ฀ ฀ ฀ ฀ ฀
systolic pause, between S and S2 is of short mind that development of a pathologic left side of the precordium may be heard
฀ ฀ and S2 occur very close S3 may be the earliest sign of heart with coronary artery disease, hypertensive
฀ ฀ ฀ ฀ ฀ ฀ failure. heart disease, cardiomyopathy, and aortic
between S2 and the start of another S is of stenosis. A pathologic S toward the right
longer duration. side of the precordium may be heard with
pulmonary hypertension and pulmonic
CLINICAL TIP
stenosis.
If you are experiencing difficulty
differentiating S1 from S2, palpate the S3 and S pathologic sounds together create
carotid pulse: the harsh sound that a quadruple rhythm, which is called a sum-
you hear from the carotid pulse is S1 mation gallop. Opening snaps occur early in
(Fig. 21-12). diastole and indicate mitral valve stenosis.
A friction rub may also be heard during the
Listen to S1. Use the diaphragm of the A distinct sound is heard in each area but Accentuated, diminished, varying, or split
฀ ฀ ฀ ฀ ฀
stethoscope to best hear S . loudest at the apex. May become softer with S฀ ฀ ฀ ฀ ฀ ฀ ฀
฀
inspiration. A split S may be heard normally ฀
in young adults at the left lateral sternal
border.

Listen to S2. Use the diaphragm of the
stethoscope. Ask the client to breathe regu
฀ ฀
CLINICAL TIP
Do not ask the client to hold his
or her breath. Breath holding will cause
any normal or abnormal split to subside.
Distinct sound is heard in each area but is Any split S2 heard in expiration is abnormal.
loudest at the base. A split S2฀ ฀ ฀ The abnormal split can be one of three
฀ ฀ ฀ ฀ 2 and P2 ฀ ฀ ฀ ฀ ฀
is normal and termed physiologic splitting.
FIGURE 21-14 Listening to heart sounds with the bell of the
It is usually heard late in inspiration at the
stethoscope.
฀ ฀ ฀ ฀ ฀ ฀ ฀
฀
Auscultate for murmurs. A murmur is a Normally no murmurs are heard. However, Pathologic midsystolic, pansystolic, and
swishing sound caused by turbulent blood innocent and physiologic midsystolic mur ฀ ฀ ฀ ฀ ฀
flow through the heart valves or great murs may be present in a healthy heart. ฀ ฀ ฀ ฀ ฀
vessels. Auscultate for murmurs across
the entire heart area. Use the diaphragm
and the bell of the stethoscope in all areas
of auscultation because murmurs have a
variety of pitches. Also auscultate with the
client in different positions as described in
the next section because some murmurs
occur or subside according to the client’s
position.

Auscultate with the client assuming
other positions. Ask the client to assume
a left lateral position. Use the bell of the
stethoscope and listen at the apex of the
FIGURE 21-12 Palpating the carotid pulse while auscultating S1. FIGURE 21-13 Auscultating S2. heart.
S and S2 heart sounds are normally present.
An S3 or S heart sound or a murmur of
mitral stenosis that was not detected with
the client in the supine position may be
revealed when the client assumes the left
lateral position.

Continued on following page

436 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS
ASSESSMENT PROCEDURE NORMAL FINDINGS
Heart (Precordium) (Continued)
Ask the client to sit up, lean forward, and S and S2 heart sounds are normally present.
exhale. Use the diaphragm of the stetho
scope and listen over the apex and along the
฀ ฀ ฀ ฀
FIGURE 21-15 Auscultating at left sternal border with client sitting up,
leaning forward, and exhaling.
Case Study
The chapter case study is now used to
demonstrate the documentation of a
physical assessment of Malcolm Win-
chester’s heart and neck vessels.
No visible jugular venous pulsations
or distention at 45 degrees. No carotid
bruits to auscultation. Carotid pulses are 2+ bilater-
ally. No visible apical impulse, heaves, or lifts over the
precordium. The apical impulse is palpable at the 5th
intercostal space, mid-clavicular line and is 1.5 cm in
diameter. S1 (loudest at the apex) and S2 (loudest at the
base) present, with no S3 or S4. Heart rate is regular at
72 beats per minute. No murmurs, rubs, or gallops are
appreciated.
ABNORMAL FINDINGS
Murmur of aortic regurgitation may be
detected when the client assumes this
position.
VALIDATING AND
DOCUMENTING FINDINGS
Validate the heart and neck vessel assessment data that you
have collected. This is necessary to verify that the data are reli-
able and accurate. Document the assessment data following
the health care facility or agency policy.
Case Study
Think back to the case study. The CCU
nurse documented the following subjec-
tive and objective assessment findings
of Malcolm Winchester’s heart and neck
vessels examination.
Biographic Data: MW, 45-year-old Afri-
can American male. Alert and oriented. Asks and answers
questions appropriately.
Reason for Seeking Health Care: “Pressure-like pain in the
middle of my chest.”
21 UÊUÊU ASSESSING HEART AND NECK VESSELS 437
History of Present Health Concern: The client presented Analysis of Data: Diagnostic
to the emergency department with complaints of chest Reasoning
pressure-like pain at rest associated with left arm dis-
comfort, nausea, and diaphoresis. He reports that the After collecting subjective and objective data pertaining to the
pain was in the center of his chest and lasted for 20 min- heart and neck vessels, identify abnormal findings and client
utes. MW also reports that he has been having episodes strengths. Then cluster the data to reveal any significant pat-
of chest pain and pressure lasting 2–3 minutes and alle- terns or abnormalities. These data may be used to make clini-
viated with rest for the past 2–3 months. He denies hav- cal judgments about the status of the client’s heart and neck
ing palpitations, dyspnea, nocturia, peripheral edema, vessels.
or indigestion. Mr. Winchester rated his pain at the
onset of this episode as 8 on a scale of 0–10. Over the
past 2 months, he rated his pain as a 4–5 on a scale of SELECTED NURSING DIAGNOSES
0–10. Currently, he denies any pain.
The following is a listing of selected nursing diagnoses that
Personal Health History: Mr. Winchester denies heart you may identify when analyzing data for this part of the
defect, murmur, history of rheumatic fever, cardiac sur- assessment.
gery or intervention, previous ECG, or medications for
heart disease. He reports having an annual lipid profile Health Promotion Diagnoses
provided by his employer. He remembers that some of ฀ ฀ ฀ ฀ ฀ ฀ ฀
the numbers were “high,” but cannot recall the actual information on exercise and low-fat diet
numbers. He admits that he has been told that his blood
pressure was a “little” high. However, he cannot recall Risk Diagnoses
any specific readings. ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Family Health History: According to Mr. Winchester, he or lack of knowledge regarding sexual activity and heart
has a strong family history of hypertension and type disease
2 diabetes. Both his parents had hypertension and type ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
2 diabetes. His mother died of a cerebral vascular acci-
dent at age 62. His father died at age 58 of an acute myo- Actual Diagnoses
cardial infarction. Maternal and paternal grandparents ฀ ฀ ฀ ฀ ฀ ฀
are deceased due to “heart problems.” ฀ ฀ ฀ ฀ ฀ ฀ ฀ -
port secondary to heart failure
Lifestyle and Health Practices: Mr. Winchester reports ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
that he started smoking at age 17 and quit at age 30. supply and demand
He smoked 2 packs per day for 13 years (26 pack ฀
years). He reports having a stressful job as a supervi- ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
sor in a local factory, and relieves stress by watching circulation
television. In the past 24 hours, Mr. Winchester has
฀ ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ SELECTIVE COLLABORATIVE
roast beef, mashed potatoes, gravy, green beans, and PROBLEMS
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
Winchester has no formal exercise regimen. However, After grouping the data, you may see various collaborative
he reports that he exercises when he does yard work problems emerge. Remember that collaborative problems dif-
every weekend. fer from nursing diagnoses in that they cannot be prevented
Mr. Winchester reports that in the past 2–3 months by nursing interventions. However, these physiologic compli-
he has “slowed down.” He wonders if maybe his heart cations of medical conditions can be detected and monitored
has been “acting up.” by the nurse. In addition, the nurse can use physician- and
nurse-prescribed interventions to minimize the complications
Mr. Winchester reports that there has been no change
of these problems. The nurse may also have to refer the client
in sexual activity. He states that he sleeps with one pil-
in such situations for further treatment of the problem. Fol-
low and feels rested after sleep.
lowing is a list of collaborative problems that may be identi-
Physical Exam Findings: There are no visible jugular fied when assessing the heart and neck vessels. These problems
venous pulsations or distention at 45 degrees. There are are worded as Risk for Complications (RC) followed by the
no carotid bruits to auscultation. Carotid pulses are 2+ problem.
bilaterally. There is no visible apical impulse, heaves or ฀ ฀ ฀ ฀
lifts over precordium. The apical impulse is palpable ฀ ฀
at the 5th intercostal space, mid-clavicular line, and is ฀ ฀
1.5 cm in diameter. S1 (loudest at the apex) and S2 ฀ ฀ ฀ ฀
(loudest at the base) present, with no S3 or S4. Heart ฀ ฀
rate is regular at 72 beats per minute. There are no mur- ฀ ฀ ฀
murs, rubs, or gallops appreciated. ฀ ฀ ฀
฀ ฀ ฀
 438 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS 21 UÊUÊU ASSESSING HEART AND NECK VESSELS 439
ABNORMAL FINDINGS

ABNORMAL FINDINGS
MEDICAL PROBLEMS ฀ ฀ ฀ ฀ ฀ ฀ ฀ ABNORMAL FINDINGS 21-1 Abnormal Arterial Pulse and Pressure Waves (Continued)
Once the data are grouped, certain signs and symptoms may (suspected combination of lack of knowledge and lack
become evident and may require medical diagnosis and treat- of perceived benefits of healthy lifestyle) BISFERIENS PULSE ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
ment. Referral to a primary care provider is necessary. Potential Collaborative Problems quick, weaker one)
Characteristics
฀ ฀ ฀
฀ ฀ ฀ Cause
Case Study ฀ ฀ ฀
฀ ฀ ฀ Causes ฀ ฀ ฀
After collecting and analyzing data for ฀ ฀ ฀
฀ ฀ ฀
Mr. Winchester, the nurse determines ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀
that the following conclusions are To view an algorithm depicting the process of diag-
฀ ฀
appropriate: nostic reasoning for this case study go to .
Nursing Diagnoses
฀ ฀ ฀ ฀ ฀ PARADOXICAL PULSE
O2 deficit PULSUS ALTERNANS Characteristics
Characteristics ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀ ฀ ฀
ABNORMAL FINDINGS 21-1 Abnormal Arterial Pulse and Pressure Waves ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
(you may need a sphygmomanometer to detect the change (the systolic pressure will decrease by more than
A normal pulse, represented in the figure, has a smooth, Causes difference) 10 mmHg during inspiration)
rounded wave with a notch on the descending slope. The ฀ ฀ ฀ ฀ ฀ ฀
pulse should feel strong and regular. The notch is not Cause Causes
฀ ฀
palpable. The pulse pressure (the difference between the ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
฀ 3
systolic and diastolic pressure) is 30–40 mmHg. Pulse pres- ฀ ฀
฀ ฀ ฀ sound on the left)
sure may be measured in waveforms, which are produced ฀ ฀ ฀
฀ ฀ ฀ ฀ ฀
when a pulmonary artery catheter is used to evaluate arte- ฀
rial pressure. ฀ ฀ ฀ ฀

BIGEMINAL PULSE
LARGE, BOUNDING PULSE Characteristics
The arterial pressure waveform consists of five parts: Anac- Characteristics ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
rotic limb, systolic peak, dicrotic limb, dicrotic notch, and a premature contraction)
฀ ฀ ฀
end diastole. The initial upstroke, or anacrotic limb, occurs ฀ ฀ ฀ ฀ ฀
as blood is rapidly ejected from the ventricle through the ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
open aortic valve into the aorta. The anacrotic limb ends
at the systolic peak, the waveform’s highest point. Arterial Causes ABNORMAL FINDINGS 21-2 Ventricular Impulses
pressure falls as the blood continues into the peripheral ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
vessels and the waveform turns downward, forming the decreased peripheral resistance Assessment of the chest may reveal abnormalities or variations of the ventricular impulse, signs of hypertension, hypertro-
dicrotic limb. When the pressure in the ventricle is less ฀ phy, volume overload, and pressure overload. Some of the abnormalities or variations include the following:
than the pressure in the aortic root, the aortic valve closes ฀
and a small notch (dicrotic notch) appears on the wave- ฀ LIFT THRILL
form. The closing of the aortic notch is the beginning of ฀ ฀ A diffuse lifting left during systole at the left lower sternal A thrill is palpated over the second and third intercostal
diastole. The pressure continues to fall in the aortic root ฀ ฀ ฀ border, a lift or heave is associated with right ventricular space; a thrill may indicate severe aortic stenosis and sys-
until it reaches its lowest point, seen on the waveform as ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ hypertrophy caused by pulmonic valve disease, pulmonic temic hypertension. A thrill palpated over the second and
the diastolic peak. decreased heart rate ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ third left intercostal spaces may indicate pulmonic stenosis
Changes in circulation and heart rhythm affect the pulse ฀ retraction at the apex, from the posterior rotation of the left and pulmonic hypertension.
and its waveform. Following are some of the variations you ฀ ฀ ฀ ventricle caused by the oversized right ventricle.
may find. ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀
aortic walls
SMALL, WEAK PULSE
฀
Characteristics ฀
฀ ฀ ฀
฀ ฀ ฀ ฀ ฀
฀ ฀
฀ ฀ ฀

Continued on following page

 440 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS 21 UÊUÊU ASSESSING HEART AND NECK VESSELS 441
ABNORMAL FINDINGS

ABNORMAL FINDINGS
ABNORMAL FINDINGS 21-2 Ventricular Impulses (Continued) ABNORMAL FINDINGS 21-4 Extra Heart Sounds

ACCENTUATED APICAL IMPULSE
A sign of pressure overload, the accentuated apical impulse
has increased force and duration but is not usually dis-
placed in left ventricular hypertrophy without dilatation
associated with aortic stenosis or systemic hypertension.
LATERALLY DISPLACED APICAL IMPULSE
A sign of volume overload, an apical impulse displaced
laterally and found over a wider area is the result of ven-
tricular hypertrophy and dilatation associated with mitral
regurgitation, aortic regurgitation, or left-to-right shunts.
Additional heart sounds can be classified by their timing in ing. A late systolic murmur typically follows, indicating
the cardiac cycle. The presence of the sound during systole mild mitral regurgitation.
or diastole helps in its identification. Some sounds extend
into both systole and diastole.
Right Left
EXTRA HEART SOUNDS DURING
SYSTOLE—CLICKS
High-frequency sounds heard just after S1 (ejection clicks)
are produced by a functioning, but diseased, valve. Clicks
can occur in early or mid-to-late systole and are best heard
through the diaphragm of the stethoscope.

Aortic Ejection Click

Heard during early systole at the second right intercostal
space and apex, the aortic ejection click occurs with the S1
S1 C1 S2
opening of the aortic valve and does not change with
respiration.
EXTRA HEART SOUNDS DURING DIASTOLE
Right Left
Opening Snap
Occurring in early diastole, an opening snap (OS) is heard
with the opening of a stenotic or stiff mitral valve. Heard
ABNORMAL FINDINGS 21-3 Abnormal Heart Rhythms throughout the whole precordium, it does not vary with res-
pirations. Often mistaken for a split S2 or an S3, the opening
Changes in the heart rhythm alter the sounds heard on aus- SINUS ARRHYTHMIA snap occurs earlier in diastole and has a higher pitch than
cultation. an S3.
With this dysrhythmia, the heart rate speeds up and slows
PREMATURE ATRIAL OR JUNCTIONAL down in a cycle, usually becoming faster with inhalation
and slower with expiration. S1 S2 S1
CONTRACTIONS Ej
These beats occur earlier than the next expected beat and are Auscultation Tip: S1 and S2 sounds are usually normal. The
followed by a pause. The rhythm resumes with the next beat. S1 may vary with the heart rate.

Auscultation Tip: The early beat has an S1 of different inten- S1 S 2 OS S1

sity and a diminished S2. S1 and S2 are otherwise similar to
normal beats.
PREMATURE VENTRICULAR CONTRACTIONS
These beats occur earlier than the next expected beat and are
followed by a pulse. The rhythm resumes with the next beat.
Auscultation Tip: The early beat has an S1 of different inten-
sity and a diminished S2. Both sounds are usually split.
Pulmonic Ejection Click
Best heard at the second left intercostal space during early S3 (Third Heart Sound)
systole, the pulmonic ejection click often becomes softer
Also called a ventricular gallop, the S3 has a low frequency
with inspiration.
and is heard best using the bell of the stethoscope at the api-
cal area or lower right ventricular area of the chest with the
Right Left patient in the left lateral position. The sound is often accen-
tuated during inspiration and has the rhythm of the word
ATRIAL FIBRILLATION AND ATRIAL ฀ 3 is the result of vibrations caused by the blood
FLUTTER WITH VARYING VENTRICULAR hitting the ventricular wall during rapid ventricular filling.
RESPONSE The S3 can be a normal finding in young children, peo-
With this dysrhythmia, ventricular contraction occurs irregu- ple with a high cardiac output, and in the third trimester
larly. At times, short runs of the irregular rhythm may appear of pregnancy. It is rarely normal in people older than age
regularly. 40 years and is usually associated with decreased myocardial
S1
contractility, myocardial failure, congestive heart failure,
Auscultation Tip: S1 varies in intensity. S1 S2
Ej and volume overload of the ventricle from valvular disease.
Midsystolic Click
Heard in middle or late systole, a midsystolic click can
be heard over the mitral or apical area and is the result of S1 S2 S3 S1
mitral valve leaflet prolapse during left ventricular empty-

Continued on following page

 442 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS
ABNORMAL FINDINGS
ABNORMAL FINDINGS 21-4 Extra Heart Sounds (Continued)
S4 (Fourth Heart Sound)
Also called an atrial gallop, S4 is a low-frequency sound
occurring at the end of diastole when the atria contract. It
is caused by vibrations from blood flowing rapidly into the
ventricles after atrial contraction. S4 has the rhythm of the
word “Ten-nes-see” and may increase during inspiration. It
is best heard with the bell of the stethoscope over the apical
area with the patient in a supine or left lateral position, and
is never heard in the absence of atrial contraction.
The S4 can be a normal sound in trained athletes and
some older patients, especially after exercise. However, it is
usually an abnormal finding and is associated with coro-
nary artery disease, hypertension, aortic and pulmonic ste-
nosis, and acute myocardial infarction.
S1 S2 S4 S1
Summation Gallop
The simultaneous occurrence of S3 and S4 is called a sum-
mation gallop. It is brought about by rapid heart rates in
which diastolic filling time is shortened, moving S3 and S4
closer together, resulting in one prolonged sound. Sum-
mation gallop is associated with severe congestive heart
disease.
S1 S2 S1
S 3 S4
EXTRA HEART SOUNDS IN BOTH
SYSTOLE AND DIASTOLE
Pericardial Friction Rub
Usually heard best in the third intercostal space to the left of
the sternum, a pericardial friction rub is caused by inflam-
mation of the pericardial sac. A high-pitched, scratchy,
scraping sound, the rub may increase with exhalation and
when the patient leans forward. For best results, use the
diaphragm of the stethoscope and have the patient sit up,
lean forward, exhale, and hold his or her breath.
The pericardial friction rub can have up to three com-
ponents: atrial systole, ventricular systole, and ventricular
diastole. These components are associated with cardiac
movement. The first two components are usually present.
If only one component is present, the rub may be con-
fused with a murmur. Friction rubs are commonly heard
during the first week after a myocardial infarction. If a sig-
nificant pericardial effusion is present, S1 and S2 sounds
will be distant.
Ventricular systole Atrial systole
Ventricular diastole
S1 S2 S1
Patent Ductus Arteriosus
Patent ductus arteriosus (PDA) is a congenital anomaly
that leaves an open channel between the aorta and pulmo-
nary artery. Found over the second left intercostal space, the
murmur of PDA may radiate to the left clavicle. It is classi-
fied as a continuous murmur because it extends through
systole and into part of diastole. It has a medium pitch and
a harsh, machinery-like sound. The murmur is loudest in
late systole, obscures S2, fades in diastole, and often has a
silent interval in late diastole.
Systole Diastole
S1 S2 S1
Venous Hum
Common in children, a venous hum is a benign sound
caused by turbulence of blood in the jugular veins. It is
heard above the medial third of the clavicles, especially on
the right, and may radiate to the first and second intercos-
tal spaces. A low-pitched sound, it is often described as a
humming or roaring continuous murmur without a silent
interval, and is loudest in diastole. A venous hum can be
obliterated by putting pressure on the jugular veins.
Systole Diastole
S1 S2 S1
21 UÊUÊU ASSESSING HEART AND NECK VESSELS 443
ABNORMAL FINDINGS
ABNORMAL FINDINGS 21-5 Heart Murmurs
Heart murmurs are typically characterized by turbulent Location
blood flow, which creates a swooshing or blowing sound Determine where you can best hear the murmur; this is the
over the precordium. When listening to the heart, be alert point where the murmur originates. Try to be as exact as
for this turbulence and keep the characteristics of heart possible in describing its location. Use the heart landmarks
murmurs in mind. in your description (e.g., the second intercostal space at the
CHARACTERISTICS left sternal border).
Heart murmurs are assessed according to various characteris- Transmission
tics, which include timing, intensity, pitch, quality, shape or The murmur may be felt in areas other than the point of
pattern, location, transmission, and ventilation and position. origin. If you determine where the murmur transmits, you
can determine the direction of blood flow and the intensity
Timing of the murmur.
A murmur can occur during systole or diastole. In addition
Ventilation and Position
to determining when it occurs, it is important to deter-
mine where it occurs: a systolic murmur can be present in a Determine if the murmur is affected by inspiration, expira-
healthy heart whereas a diastolic murmur always indicates tion, or a change in body position.
heart disease. Systolic murmurs can be divided into three
MIDSYSTOLIC MURMURS
categories: midsystolic, pansystolic, and late systolic. Dia-
stolic murmurs can be divided into three categories: early The most common type of heart murmurs—midsystolic
diastolic, mid-diastolic, and late diastolic. murmurs—occur during ventricular ejection and can be
innocent, physiologic, or pathologic. They have a crescendo–
Intensity decrescendo shape and usually peak near midsystole and
stop before S2.
Six grades describe the intensity of a murmur.
Grade 1: Very faint, heard only after the listener has “tuned Innocent Murmur
in”; may not be heard in all positions
Not associated with any physical abnormality, innocent
Grade 2: Quiet, but heard immediately on placing the
murmurs occur when the ejection of blood into the aorta
stethoscope on the chest
is turbulent. Very common in children and young adults,
Grade 3: Moderately loud
they may also be heard in older people with no evidence
Grade 4: Loud
of cardiovascular disease. A patient may have an innocent
Grade 5: Very loud, may be heard with a stethoscope partly
murmur and another kind of murmur.
off the chest
Grade 6: May be heard with the stethoscope entirely off
the chest
Pitch
S1 S2 S1
Murmurs can assume a high, medium, or low pitch.
Location: Second to fourth left intercostal spaces between
Quality the left sternal border and the apex
The sound murmurs make has been described as blowing, Radiation: Little radiation
rushing, roaring, rumbling, harsh, or musical. Intensity: Grade 1 to 2
Pitch: Medium
Shape or Pattern Quality: Variable
The shape of a murmur is determined by its intensity from Position: Usually disappears when the patient sits
beginning to end. There are four different categories of Physiologic Murmur
shape: crescendo (growing louder), decrescendo (growing
Caused by a temporary increase in blood flow, a physio-
softer), crescendo–decrescendo (growing louder and then
logic murmur can occur with anemia, pregnancy, fever, and
growing softer), and plateau (staying the same throughout).
hyperthyroidism.
S1 S2 S1 S2
S1 S2 S1
S1 S2 Location: Second to fourth left intercostal spaces between
S1 S2 the left sternal border and the apex
Radiation: Little radiation
Intensity: Grade 1 to 2
Pitch: Medium
S1 S2 Quality: Harsh
Continued on following page
 444 UNIT 3 UÊUÊU NURSING ASSESSMENT OF PHYSICAL SYSTEMS
ABNORMAL FINDINGS
ABNORMAL FINDINGS 21-5 Heart Murmurs (Continued)
Murmur of Pulmonic Stenosis
A pathologic murmur, the murmur of pulmonic stenosis
occurs from impeded flow across the pulmonic valve and
increased right ventricular afterload. Often occurring as a
congenital anomaly, the murmur is commonly found in
children. Pathologic changes in flow across the valve, as in
atrial septal defect, may also mimic this condition.
With severe pulmonic stenosis, the S2 is widely split
and P2 is diminished. An early pulmonic ejection sound
is also common. A right-sided S4 may also be present, and
the right ventricular impulse is often stronger and may be
prolonged.
S2
S1 Ej A2 P2 S1
Location: Second and third intercostal spaces
Radiation: Toward the left shoulder and neck
Intensity: Soft to loud (may be associated with a thrill if
loud)
Pitch: Medium
Quality: Harsh
Position: Loudest during inspiration
Murmur of Aortic Stenosis
The murmur of aortic stenosis occurs when stenosis of
the aortic valve impedes blood flow across the valve and
increases left ventricular afterload. Aortic stenosis may
result from a congenital anomaly, rheumatic disease, or
a degenerative process. Conditions that may mimic this
murmur include aortic sclerosis, a bicuspid aortic valve, a
dilated aorta, or any condition that mimics the flow across
the valve, such as aortic regurgitation.
If valvular disease is severe, A2 may be delayed, resulting
in an unsplit S2 or a paradoxical split S2. An S4 may occur as
a result of decreased left ventricular compliance. An aortic
ejection sound, if present, suggests a congenital cause.
May be diminished
S1 S2 S1
Location: Right second intercostal space
Radiation: May radiate to the neck and down the left ster-
nal border to the apex
Intensity: Usually loud, with a thrill
Pitch: Medium
Quality: Harsh, may be musical at the apex
Position: Heard best with the patient sitting and leaning
forward, loudest during expiration
Murmur of Hypertrophic Cardiomyopathy
Caused by unusually rapid ejection of blood from the left
ventricle during systole, the murmur of cardiac hypertrophy
results from massive hypertrophy of the ventricular mus-
cle. There may be a coexisting obstruction to blood flow.
If there is an accompanying distortion of the mitral valve,
mitral regurgitation may result. The patient may also have
an S3 and an S4. There may be a sustained apical impulse
with two palpable components.
S1 S2 S1
Location: Third and fourth left intercostal space, decreases
with squatting, increases with straining down
Intensity: Variable
Pitch: Medium
Quality: Harsh
PANSYSTOLIC MURMURS
Occurring when blood flows from a chamber with high
pressure to a chamber of low pressure through an orifice
that should be closed, pansystolic murmurs are pathologic.
Also called holosystolic murmur, these murmurs begin with
S1 and continue through systole to S2.
Murmur of Mitral Regurgitation
Occurring when the mitral valve fails to close fully in sys-
tole, the murmur of mitral regurgitation is the result of
blood flowing from the left ventricle back into the left
atrium. Volume overload occurs in the left ventricle, caus-
ing dilatation and hypertrophy.
Diminished
S1 S2 S3 S1
The S1 sound is often decreased, and the apical impulse
is stronger and may be prolonged. Left ventricular volume
overload should be suspected if an apical S3 is heard.
Location: Apex
Radiation: To the left axilla, less often to the left sternal
border
Intensity: Soft to loud, an apical thrill is associated with
loud murmurs
Pitch: Medium to high
Quality: Blowing
Position: Heard best with patient in the left lateral
decubitus position; does not become louder with
inspiration
ABNORMAL FINDINGS 21-5 Heart Murmurs (Continued)
Murmur of Tricuspid Regurgitation
Blood flowing from the right ventricle back into the right
atrium over a tricuspid valve that has not fully closed causes
the murmur of tricuspid regurgitation. Right ventricular
failure with dilatation is the most common cause and usu-
ally results from pulmonary hypertension or left ventricular
failure.
With this murmur, the right ventricular impulse is stron-
ger and may be prolonged. There may be an S3 along the
lower left sternal border, and the jugular venous pressure is
often elevated, with visible v waves.
Location: Lower left sternal border
Radiation: To the right of the sternum, to the xiphoid area,
and sometimes to the mid-clavicular line; there is no
radiation to the axilla
Intensity: Variable
Pitch: Medium to high
Quality: Blowing
Position: May increase slightly with inspiration
Ventricular Septal Defect
A congenital abnormality in which blood flows from the
left ventricle into the right ventricle through a hole in the
septum, a ventricular septal defect causes a loud murmur
that obscures the A2 sound. Other findings vary depending
on the severity of the defect and any associated lesions.
Location: Third, fourth, and fifth left intercostal space
Radiation: Often wide
Intensity: Very loud, with a thrill
Pitch: High
Quality: Harsh
Position: Increases with exercise
DIASTOLIC MURMURS
Usually indicative of heart disease, diastolic murmurs occur
in two types. Early decrescendo diastolic murmurs indicate
flow through an incompetent semilunar valve, commonly
the aortic valve. Rumbling diastolic murmurs in mid- or late
diastole indicate valve stenosis, usually of the mitral valve.
21 UÊUÊU ASSESSING HEART AND NECK VESSELS 445
ABNORMAL FINDINGS
Murmur of Aortic Regurgitation
Occurring when the leaflets of the aortic valve fail to close
completely, the murmur of aortic regurgitation is the result
of blood flowing from the aorta back into the left ventricle.
This results in left ventricular volume overload. An ejection
sound also may be present. Severe regurgitation should be
suspected if an S3 or S4 is also present. The apical impulse
becomes displaced downward and laterally, with a widened
diameter and increased duration. As the pulse pressure
increases, the arterial pulses are often large and bounding.
S1 S2 S1
Location: Second to fourth left intercostal space
Radiation: May radiate to the apex or left sternal border
Intensity: Grade 1 to 3
Pitch: High
Quality: Blowing, sometime mistaken for breath sounds
Position: Heard best with the patient sitting, leaning forward.
Have the patient exhale and then hold his or her breath.
Murmur of Mitral Stenosis
The murmur of mitral stenosis is the result of blood flow
across a diseased mitral valve. Thickened, stiff, distorted
leaflets are usually the result of rheumatic fever. The mur-
mur is loud during mid-diastole as the ventricle fills rapidly,
grows quiet, and becomes loud again immediately before
systole, as the atria contract. In patients with atrial fibrilla-
tion, the second half of the murmur is absent because of
the lack of atrial contraction.
The patient also has a loud S1, which may be palpable
at the apex. There is often an opening snap (OS) after S2. P2
becomes loud and the right ventricular impulse becomes
palpable if pulmonary hypertension develops.
S1 S1
Accentuated
S2 OS
Location: Apex
Radiation: Little or none
Intensity: Grade 1 to 4
Pitch: Low
Quality: Rumbling
Position: Best heard with the bell exactly on the apex and
the patient turned to a left lateral position. Mild exercise
and listening during exhalation also make the murmur
easier to hear.